Organisational learning, or organised irresponsibility? Risk, opacity and lesson learning about mental health related deaths

Figures & data

Table 1. Organisational responses to PFDs.

Agency	Number of responses requested by Coroner	Percentage of total responses requested
NHS Trust^6	133	39 %
Government Agency	62	18 %
Clinical Commissioning Groups (CCGs)	25	7 %
Police	24	7 %
NHS England	23	7 %
County Council	18	5 %
Prison and Probation service	14	4 %
University Health Board	11	3 %
Ambulance Service	11	3 %
CQC	9	3 %
Private Health Provider	8	2.5 %
GP	5	1 %
NHS Improvement	2	0.5 %

Table 2. Responses as a percentage of PFDs received by organisation.

Agency	% of replies returned to coroner
NHS Improvement	100 %
GP	80 %
County Council	66 %
Private Health Provider	66 %
NHS England	65 %
Government Agencies	58 %
Clinical Commissioning Group	52 %
CQC	50 %
NHS Trust	47 %
University Health Board	45 %
Police	45 %
Prison and Probation Services	28 %
Ambulance Services	27 %